NEW YORK -- City health officials are investigating the death of a baby boy who was one of three infants to contract herpes after a rabbi circumcised them.

Ten days after Rabbi Yitzhok Fischer performed religious circumcisions on twins last October, one died of herpes and the other tested positive for the virus, according to complaint filed by the health department in Manhattan Supreme Court.

The complaint, reported in Wednesday's edition of the New York Daily News, also said health officials later found a third baby who had contracted herpes after being circumcised by Fischer in late 2003.

Under Jewish law, a mohel -- someone who performs circumcisions -- draws blood from the circumcision wound. Most mohels do it by hand, but Fischer uses a rare practice where he uses his mouth.

Fischer's lawyer, Mark Kurzmann, told the Daily News that Fischer was cooperating with the investigation, although it's unclear whether Fischer submitted to the city's request for a blood test.

"My client is known internationally as a caring, skilled, and conscientious mohel," Kurzmann said.

NEW YORK - (KRT) - New York city health officials are investigating whether a baby boy died after contracting herpes from the rabbi who circumcised him, the New York Daily News has learned.

The probe was launched after city officials realized that three infants in the city who tested positive for herpes last year all were circumcised by Rabbi Yitzchok Fischer. The Rockland County-based Fischer is a prominent mohel - someone who performs religious circumcisions.

Under Jewish law, a mohel is supposed to draw blood from the circumcision wound to remove impurities. While many mohels do it by hand, Fischer uses a practice little known outside Orthodox communities called "metzizah bi peh," in which the mohel uses his mouth.

On Oct. 16, 2004, Fischer performed a bris, or religious circumcision, on twins. Ten days later, one infant died of herpes, and the other tested positive for the virus, according to papers filed in Manhattan Supreme Court by city lawyers.

A few weeks later, city Health Department officials found a third baby, on Staten Island, that also tested positive for herpes after being circumcised by Fischer in late 2003, the papers say.

Herpes is far more dangerous to infants than adults because of babies' fragile immune systems. The health status of the two surviving boys was not clear yesterday.

The city "is concerned that the possible transmission of herpes simplex virus type 1 in infants may be continuing as a result of defendant's practice of metzizah bi peh," city lawyers wrote in the complaint, dated Dec. 22. "Defendant's conduct to date constitutes a threat to the public health."

The custom of metzizah is thousands of years old. But experts said that these days, many mohels breathe in through a sterile tube to draw the blood instead of using their mouths directly on the wound, although in some Orthodox sects, the oral practice is mandatory.

The city asked Fischer to submit to a blood test in November, and ordered him to stop performing metzizah by mouth while waiting for the results, court papers show. Officials told him to use a sterile tube and gloves in the meantime.

But the Health Department got a report that Fischer wasn't following the order, so the city filed the legal complaint to compel him do so.

Fischer, 66, declined to comment Tuesday.

His lawyer, Mark Kurzmann, wouldn't say whether Fischer has done the blood test, citing medical confidentiality. But he said Fischer is "cooperating with the city's investigation to resolve this matter."

"My client is known internationally as a caring, skilled and conscientious mohel," Kurzmann said.

He suggested the babies could have contracted herpes elsewhere. He also said there are concerns about the government regulating religious practices.

City lawyers declined to comment.

Health officials, aware of the sensitivity of the issue, have been talking extensively to community leaders.

"There's been a constructive dialogue between the community and the Department of Health, and we're working with (them) to ensure the safety of all our city's children," said Arie Lipnic, spokesman for City Councilman Simcha Felder.

When Gena Sokolovsky was eight days old in the vallage of Skargarod, Ukraine, 12 years ago, a circumcision was very difficult to obtain. The procedure was discouraged by the Soviet Union. A few mohels performed secretly, but the difficulties and peer pressure kept most Jewish families from holding a bris for their newborn boys.

But Gena Sokolovsky "always felt I wanted to be a real Jew." And last Thursday, Gena, now living in the Boston area and attending the New England Hebrew Academy/Lubavitz Yeshiva, took that crucial step. Rabbi Yitzchok Fischer, who says he has done 12,000 adult circumcisions in the last 25 years, performed the operation, with Hebrew Academy executive director Rabbi Chaim Ciment serving as sandek.

Circumcisions of adults are not uncommon in Boston, especially among the growing Russian Jewish population. But the operation is relatively rare among adolescent boys in the area.

(cont)The circumcision was the second at Hebrew Academy in as many months. Boris Drizik, also 12, celebrated his bris last months. Drizik said he hadn't wanted to be circumcized in the Ukraine because "I didn't want to be different from the other kids." But when the family moved to the United States and his father, who had had a bris, wanted him to undergo the operation, he agreed.

"Once Gena saw that Boris had had a bris and he told him it was `no problem,' Gena was ready," said the boy's uncle, Michael Sokolovsky, who served as Gena's interpreter. "It was his own decision. His parents didn't coerce him."

Now, for the first time, Gena will be able to participate in the korben Pesach, the Passover sacrifice. And he's preparing for his bar mitzvah when he turns 13 in November.

"He would have become bar mitzvah anyway [without the circumcision], but it would have been incumbent on him to have it done. Now, he will be ready to observe all the mitzvot," Ciment said.

I think it's important to note that the herpes virus that may have been transmitted by this mohel is not the sexually transmitted strain of the virus, but the strain that causes cold sores. Obviously, as horrific as the story is, if true, the whole tone is changed when you think the rabbi is carrying a STD.

Objective. Genital neonatal herpes simplex virus type 1 (HSV-1) infection was observed in a series of neonates after traditional Jewish ritual circumcision. The objective of this study was to describe neonate genital HSV-1 infection after ritual circumcision and investigate the association between genital HSV-1 after circumcision and the practice of the traditional circumcision.

Results. The average interval from circumcision to clinical manifestations was 7.25 ± 2.5 days. In all cases, the traditional circumciser (the mohel) had performed the ancient custom of orally suctioning the blood after cutting the foreskin (oral metzitzah), which is currently practiced by only a minority of mohels. Six infants received intravenous acyclovir therapy. Four infants had recurrent episodes of genital HSV infection, and 1 developed HSV encephalitis with neurologic sequelae. All four mohels tested for HSV antibodies were seropositive.

Conclusion. Ritual Jewish circumcision that includes metzitzah with direct oral–genital contact carries a serious risk for transmission of HSV from mohels to neonates, which can be complicated by protracted or severe infection. Oral metzitzah after ritual circumcision may be hazardous to the neonate.

Biblical sources dictate routine ritual circumcision at 8 days of age for Jewish boys. This procedure is widely accepted, and 60% to 90% of newborn boys of the Jewish population in the United States undergo this procedure,1,2 which also has an important cultural and historical role. The medically beneficial versus harmful consequences have long been debated.3 Circumcision has been reported to reduce the incidence of urinary tract infections in infants,4 young boys under the age of 2 years,5 and preschool boys.6 Pathologic phimosis and paraphimosis is precluded by the absence of a foreskin, and balanitis and posthitis (inflammation of the prepuce) primarily affect uncircumcised male individuals. Virtually all sexually transmitted diseases,7 including human immunodeficiency virus infection,6,8 are reported to be more common in uncircumcised men.

Both immediate and long-term complications of ritual circumcision are rare, probably because of the specific and meticulous precautions required by Jewish law. Only an experienced and qualified circumciser, the mohel, is allowed to perform circumcision. Historically, Jewish ritual circumcision consists of 3 parts: 1) the excision of the outer part of the prepuce (milah), 2) slitting of the foreskin's inner lining to facilitate the total uncovering of the glans (peri'ah), and 3) the sucking of the blood from the wound. Formerly, the mohel took some wine in his mouth and applied his lips to the part involved in the operation and exerted suction, after which he expelled the mixture of wine and blood into a receptacle provided for this purpose; this procedure was repeated several times until bleeding stopped (metzitzah). The first 2 parts are the act of circumcision, whereas the removal of the blood was done for medical reasons of wound care. However, the ancient procedure of metzitzah also carries a risk of infection, and currently most mohels use an appropriate suction device, such as a mucus extractor.

The incidence of neonatal herpes simplex virus (HSV) infections ranges from 1 to 6 per 20 000 live births. Most neonatal HSV infections result from exposure to infectious maternal genital secretions at delivery. Postnatal transmission usually results from nongenital infection of a caregiver, including parent or nursery personnel with oral lesions.9 Nosocomial transmission in nurseries has been documented.9 We present 8 infants who developed neonatal HSV-1 infection after oral metzitzah following ritual circumcision, most probably as a consequence of transmission by the mohel's saliva.

It is fortunate that two years ago, the Chief Rabbinate approved the use of suction devices to remove blood from the circumcision wound if there is a risk of spreading diseases such as AIDS, hepatitis B or C, or genital herpes. The latest issue of Pediatrics contains an article written by a Ben-Gurion University/Soroka University Medical Center team reporting on eight babies who developed genital herpes - one of them suffering serious brain damage as a complication - because the mohel (ritual circumciser) sucked the blood directly.

The team, headed by Dr. Benjamin Gesundheit, wrote that only a minority of circumcisers perform direct metzitza, in which they take wine in their mouths and suck the blood from the wound at the end of the baby's penis until the bleeding stops. Today, they conventionally suck the blood through a glass tube with cotton wool in the middle, or use a special suction device.

(cont)According to the article, the eight boys contracted genital herpes four to 11 days after their brit mila. The four circumcisers were tested and found to have antibodies to the main viral cause of oral herpes sores, which can also cause genital infections. The herpes simplex-type 1 virus can appear for a number of days to weeks in people who show no symptoms of infection, or who have only a cold sore.

Six of the babies were treated intravenously with an antiviral medication, but four suffered repeated attacks of genital herpes; in one case, it spread to the brain and caused neurological damage.

"The process of replacing ancient custom with modern wound care has to be encouraged by a heightened awareness of this potentially life-threatening complication," the team wrote. "We suspect, therefore, that this is underreported for cultural reasons, and that the studies described here are only the 'tip of the iceberg' of the true incidence of the disease."...

An ancient procedure that is part of ritual circumcisions, one that has been found to spread herpes and other dangerous illnesses, is still used in Toronto, though infrequently.

Oral metzitzah, the practice in which a mohel sucks blood from an infant's circumcised penis, has been supplanted by more hygienic and effective ways of cleaning the wound, said Dr. Aaron Jesin, a Toronto-based mohel. While metzitzah remains a required part of the circumcision ritual, most practitioners employ a glass tube to clean the wound, he said.

However, there are groups in Toronto today who continue to employ mohels who use oral metzitzah, said Rabbi Moshe Mordechai Lowy, a spokesman for the Orthodox Va'ad Harabonim in Toronto. "Those in the Torah world, the yeshiva world, use the procedure, unless there's a problem," he said.

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Last month, a group of researchers in Canada and Israel published a report in the medical journal Pediatrics, which found eight babies who were infected with the herpes virus likely contracted their illnesses through oral metzitzah. Most of the infants were found in Israel but one, who was circumcised in 1994, was from Toronto.

The researchers' report, published in the journal's Aug. 2 edition, stated that in the cases studied, infection was transmitted by the mohel to the infant orally. All the mohels involved in the circumcisions tested positive for the herpes antibody.

One of the children became seriously ill with encephalitis, while the Toronto baby spent 26 days in hospital, the report noted.

"Our findings provide evidence that ritual Jewish circumcision with oral metzitzah may cause oral-genital transmission of HSV infection, resulting in clinical disease... Furthermore, oral suction may not only endanger the child but also may expose the mohel to human immuno-deficiency virus or hepatitis B from infected infants. The same conclusion that led the talmudic sages once to establish the custom of metzitzah for the sake of the infant could now be applied to persuade the mohel to use instrumental suction," the researchers concluded.

Dr. Gideon Koren, professor in the department of clinical pharmacology and toxicology at the Hospital for Sick Children and the University of Toronto, is one of the authors of the report. He believes "some mohels still use their mouths for suction, but [they] use plastic pipes."

Even in Israel, he said, oral suction is employed "by a small minority and by all accounts, the rabbanut [rabbinic councils] told them to stop it. It's not a system that mainstream Judaism uses. I wouldn't even imagine a backward and primitive procedure [like that] still exists."

Given the existence of anti-Semitism, "the last thing we need is people to say Jews are abusing children," Koren added.

Jesin said he used oral metzitzah a few times when he first began as a mohel in 1978 but soon gave it up. He now uses a glass tube, which, he said, complies with the Gemarah requirement "to draw the blood from the far places [within the wound]."

Jesin cited renowned halachic authority Rabbi Moshe Tendler of Yeshiva University's department of talmudic law and Jewish medical ethics, who asserts it is forbidden to perform metzitzah without an instrument.

Speaking from New York, Rabbi Tendler, one of the report's co-authors, said the procedural elements of ritual circumcision are contained in the Talmud, which breaks down circumcision into three parts. In the first, orla, the foreskin is removed, while in the second, priah, the mucous layer is removed. The third part, metzitzah is clearly "a medical requirement, not a ritual requirement," and can therefore even be performed on the Sabbath, he said.

With advances in medical techniques and knowledge, mohels are required by Jewish law to do what is in the baby's best interests, and that would mean following current medical thinking and avoiding oral suction of the penis, Rabbi Tendler said.

Rabbi Tendler said most mohels comply with this approach, but some chassidic groups, including Satmars and Lubavitch, still employ traditional methods.

Rabbi Lowy acknowledged that "haredim or those who feel they still want to go with the old way of thousands of years [of tradition] and they feel the mohel is careful" accept oral metzitzah.

He mentioned the Satmar, Bobov, Lubavitch and other communities who generally comply with the traditional way of performing metzitzah.

A 1990 book by Rabbi Yonason Binyomin Goldberger made the case for oral metzitzah and included kabbalisitc reasons for doing so, he continued. At the time, the practice was endorsed by a number of doctors, Rabbi Lowy said.

In 1994, when the Toronto baby took sick, the Va'ad Harabonim investigated the case and issued a brief statement saying that "there is no clinical basis in ceasing to perform metzitzah b'peh (orally)." However, the rabbinical council also stated if the mohel exhibits cold sores, lesions or flu, oral metzitzah should be avoided, he added.

Koren suggested that as good consumers, Jewish parents should ask mohels what technique they plan to use and govern their choices accordingly.

Dr. Rochelle Schwartz, Toronto's second female mohelet, said Reform practitioners employ a clamp that permits a small amount of bleeding, and then they draw the blood with sterile gauze. She also uses a powder to cauterize the wound.

Schwartz, who has performed ritual circumcisions for eight years, said there are safer ways of performing metzitzah than by using the mouth. "It's really very unhygienic. I can't see a value in it."

The mouth, she continued, is loaded with bacteria, and most mohels would be unaware if they are developing a cold sore.

"Yes, it's traditional but it's also a surgical procedure. You want to keep the area as clean and hygienic and sterile as possible," she said.

Schwartz's father, Harry, recalls how the practice of metzitzah was performed on his brother, with disastrous consequences. In 1919 in the small Polish town of Tyrava, between Krakow and Lvov, an older brother was born. As his parents related the story to him, a mohel employed the traditional method of metzitzah on his brother. Unfortunately the mohel had a mouth full of rotting teeth and an infection was passed on to his brother, who died a few days later.

There was nothing to be done for his brother, Schwartz recalled, but times have changed since then. "My grandmother was 65 years old, got pneumonia and the doctor said there was nothing to do and she passed away. Now, a pneumonia is nothing," he said, noting the advances in medical science.

NEW YORK -- Nearly a year after the British medical journal Lancet reported that a mohel might -- might -- have been the vector in a transmission of AIDS, a quiet but potentially explosive debate is going on among the rabbinical and medical elite over whether to regulate the time-honored ritual of circumcision.

The article by a team from the New York City Department of Health, which was published in the Aug. 20, 1994, number of Lancet, explored a mysterious case of a newborn who had contracted HIV even though his parents and grandparents tested negative. Of the several possibilities that it raised, one -- and it was strictly a possibility -- was that a circumcision performed outside the hospital by a "circumciser" was to blame.

While the authors concluded it was "unlikely" the baby had contracted AIDS from being circumcised, they did not rule it out entirely, nor, for that matter, did they definitively pinpoint how the baby had contracted the fatal disease. The researchers said that it had probably been the result of some mishap inside the hospital.

Amid all the scientific jargon, some were able to spot a potentially significant health hazard: the possibility that as AIDS continues to spread among heterosexuals as well as in the Orthodox community, revered methods of circumcision may need to be revamped. In a letter published in Lancet on Oct. 8, 1994, Dr. Sanford Kuvin, an infectious-disease specialist in Florida, sounded the alarm, using the original article as a jumping-off point. "In this decade of emerging diseases, the risks of acquiring HIV or hepatitis B during circumcision have never been addressed," Dr. Kuvin said. "Yet the standards of infection control in ritual circumcision are totally unregulated."

Even prior to the Lancet article, the issue of what to do about ritual circumcisions had been rankling Orthodox communities all over America. Circumcision itself is coming under attack by what the Jewish Telegraphic Agency, in a dispatch this week, calls "increasingly vocal" opponents, some of whom are setting up organizations advocating an end to a practice that has been a central tenet of Judaism. Rabbis dismiss some, though not all, of the opposition to circumcision as veiled anti-Semitism.

Rigorous Training

The discussion that has surfaced in the wake of the Lancet article is not a part of the anti-circumcision movement. It centers on the question of how best to protect individuals in the age of AIDS. Although in some cities, like New York, mohels are certified by boards and receive rigorous training, not all don surgical gloves when performing circumcisions, one of the most basic precautions when performing what is called an "invasive procedure." Some mohels among the charedim continue to practice metzitzah b'peh, which involves sucking the blood of the infant's penis. This is sometimes done by mouth, sometimes with a syringe or suction tube. That practice, which is considered crucial among Chasidim, is coming under fire, its dangers touted despite generally low rates of AIDS among religious Jews and the fact that the charedim maintain that the risks of HIV spreading are minute.

Rinse With Rum

The debate is pitting two titans of medical ethics, Rabbi J. David Bleich and Rabbi Moshe Tendler, against one another. Rabbi Bleich believes the risks of AIDS are so minimal among the Orthodox that no radical reforms are necessary; moreover, he defends the practice of metzitzah b'peh and says that any risk of infection to the mouth can be eliminated by having the mohel rinse his mouth with 151 proof rum to kill off AIDS or other viruses. Rabbi Tendler, while also extolling the safety of circumcision, does urge stricter standards and states categorically that metzitzah b'peh "without a barrier" should be stopped. He dismisses Rabbi Bleich's approach of gargling with liquor as "folk medicine."

"We are dealing with a disease that is 100% fatal -- there is no amount of precaution that is too much," Dr. Tendler told the Forward. "We recommend that mohels do not use metzitzah b'peh. The Chasidic mohels still do, and it is not to be criticized -- I know from 3,500 years experience that it is safe. However, a mohel who does it now I believe is foolhardy. He is endangering his own life, not the baby's life, because sadly, the HIV virus has crept into the heterosexual [and Jewish] community."

Rabbi Tendler, who chairs the biology department at Yeshiva University and teaches talmudic law and medical ethics, makes it clear, however, that he believes the risk of AIDS transmission -- certainly from a mohel to a newborn -- is virtually non-existent. Circumcision, says Rabbi Tendler, especially as it is practiced in the Orthodox community, is safe. However, while noting that the custom of sucking the blood by mouth was in decline and that many mohels were using a syringe, he concedes it is still performed in some circles in exactly the manner of ancient times. In addition, even in the age of AIDS, he said, some mohels opt not to wear rubber gloves. He said that because of the many communities, it is impossible to impose uniform regulations; he and others can only make "recommendations" and hope they will be followed.

`Zero' Danger

Rabbi Bleich says he, too, has made recommendations to tighten safety standards for mohels. While the risk of contracting AIDS is "remote," he feels there is no need to take needless risks. He has urged mohels to don rubber gloves. "The danger is more to the circumciser than to the baby," Rabbi Bleich declares. The ethicist, who is also a professor of Talmud and Jewish law at Yeshiva University, states: "The danger to the baby of [contracting] AIDS is zero unless the mohel has become infected, and I don't know of a single mohel who's become infected."

The two rabbis appear to diverge on the issue of metzitzah b'peh and how it should be practiced. "The practice is rooted in Jewish law and tradition," says Rabbi Bleich, adding, "I don't think the AIDS scare is enough to change the practice." He says he has investigated the matter, and that it is not dangerous to the baby or the mohel. As a way to protect the circumciser, he recommends that all new Jewish mothers be tested for the HIV virus; "I have told the mohels to insist on such tests," he disclosed.

Ironically, there is a controversy in New York over whether a mother may be required to submit to an AIDS test and, if found to be positive, be informed of the results.

`Too Many Rabbis'

While Dr. Kuvin agrees that the risk of contracting AIDS through circumcision is small, he also asserts that it is "entirely preventable." The growth of the epidemic is such that it is bound to hit the Orthodox Jewish community, he feels. Dr. Kuvin says that in Israel he has observed circumcisions performed by a mohel with his bare hands. "As day follows night, we will have cases that will surface," says Dr. Kuvin, who runs his own center for infectious diseases at Hebrew University's medical school in Israel.

Across the country, some Jewish communities have instituted reforms. In Baltimore, says Rabbi Tendler, the rabbis have moved to ban metzitzah b'peh by mouth; this ban can't be done in New York, says Rabbi Tendler: "New York does not have the ability to reach a consensus -- [there are] too many rabbis."

The general counsel at Agudath Israel of America, David Zwiebel, was cautious: "Clearly there are different views in the community, and it is a matter that's been given serious consideration by the rabbis." Mr. Zwiebel said that as evidence on the spread of AIDS accumulates, "People in the halachic community will be paying very close attention."